Abstract

The move to electronic discharge summary systems was anticipated to solve the longstanding problems associated with poor data quality and reduce delay in the production and transmission of discharge summaries between secondary andprimary care health care providers in the UK National Health Service. A consequence of investment in a national IT infrastructure for electronic health records has focused attention on template design and the IT system requirements.The routine practices of doctors involved in discharge summary construction, and other factors that contribute to the problems of delay and data quality, have been less well explored.

This study aimed to gain an understanding of paper-based discharge summary construction in a secondary care context in order to identify and analyse the implications for improving electronic discharge summary systems, and potentiallyavoid inadvertent transfer of inherent problems. A mixed method case study design was used to examine the patient discharge process and the construction of discharge summaries in one NHS Hospital Trust. Data was collected throughsemi-structured interviews with hospital doctors (n=10) and simulated discharge summary production (n=10). A syntactic analysis was also performed ondischarge summaries (n=11) and proformas (n=3). The data was analysed thematically and inductively in order to identify the factors that contribute to the twin problems of data quality and delay associated with discharge summaries. Thepragmatic, semantic, syntactic conceptual framework (Morris, 1938), and Speech Act (Austin, 1962) and Mental Frame (Minsky,1981) theories, were used to analyse how information contained in discharge summaries was represented, interpreted and used.

This study found that moving from a paper based to an electronic discharge summary system will not necessarily resolve the problems of poor data quality and delayed production of discharge summaries. More comprehensive solutions are required in order to facilitate more effective discharge summary communication between secondary and primary care health professionals, and toaddress entrenched custom and practice in current hospital practice. These include uni-professional (medical) orientation of discharge summaries, attitude of senior doctors, inadequate preparation of junior doctors, inconsistent data entry including absence of common usage of short forms and abbreviations, and little accountability for quality control.

Recommendations include training for junior doctors, regulating the use of shortened forms, improving the features of data entry systems, structuring the clinical coding data and introducing systems to ensure greater organizational accountability for effective discharge communication. More comprehensive change related to the introduction of multidisciplinary contribution discharge summary construction and integration of discharge summary standards in care pathways may improve overall discharge summary quality.